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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601"'�HAZELTON AVE., STOCKTONi CA Telephone (209)'466..67 81 PERMIT EXPIRES I YEARFROM DATE ISSUED -k(Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein''described. This application is made"in compliance with San Joaquin County Ordinance.No.549 forsewageor No.-1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.t Job Address _ 3• eA � �City � ' Lot Size PM— Owner's Name f/[/�fF/�C�JQ/�[ �N�t� ,� 3j,. � Address 40,UWC�- Q Phone 6" 0 Contractor.s.Name, o"�. License.No. - TYPE OF WELL/PUMP: Phone �•«_-.. NEW WELL' ❑ WELL REPLACEMEl�ITG] DESTRUCTION ❑ tPUIUIP INSTALLATION❑ T """" . .� - SYSTEM'REP4lR ❑ OTHER"❑ DISTANCE 6' REST:-,SEPTIC 7`ANK `9f,,, r SEWER LINES 4" DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ fndusiria! W-' El Open Bottom L3 Manteca Dia. ca Of Well Exvation C) Dia.Gravel Pack Tracy Type of Casing Dia. f Well Casing -� C: Domestic/ . ❑ Other Specifications ❑ Delta Depth of Grout Seal !❑ Irrigation ^Jq Type of Grout ---Approx. Depth '❑ Eastern Surface Seal Installed by [Repair Work Done ❑ Type of Pump H.P. State Work Done. �) 'Well Destruction ❑ Well Diameter. Sealing Material (top 50') 1 11 � f5- I Depth Filler Material (Below 50') /TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR ADDITION L7 DESTRUCTION ❑ (No septic system permitted if public sewer is ' available within 200 feet.) _ einstallation will serve: 'Residence Commercial_ Other Number of living L Charactunits:—/— Number of bedrooms f j ' r er of soil to a depth of 3 feet: t Water table depth SEPTIC TANK tk. [Er Type/Mfg PKG: TREI p ATMENT PLT. ❑ Capacity—A?-&-0 No. Compartments Z-- - / Method of Disposal t `Dista'nce to nearest: Well Foundation Property Line LEACHING LINE—❑ IN,.& Length of lines 67 a O r Total length/size ./Q"Q .FIL--TER BED � �"�❑ D tante to nearest: Well Imo" Foundation Property Line Z SEEPAGE PITS ❑ -�Dopth o n" Size_ `tet j4 14 V 7 Number SUMPS ' " 4 ❑J"Distance io'nea est; Well a��" Foundation Zo Property Line - S—O DISPOSAL PONDS--gip i I he Aeby certify that I have prepared-this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and Yegulationsof'the-San Joaquin Local Health District. Home owner or licensedagent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person"in§such manner as to become subject"to workman's compensation laws of California."Contractor s hiring or sub contracting signature certifies the following:"I certify that in the performance of the work for which thisermit is issued,I shall employ Maws of California:"0 - p p Y persons subject to workman's compensa- tion . The iapplic must cal r all required inspect' s. Complete drawing an reverse side. L Signed Title: Date: Q 1 OR DEP.ARTKIENT USE ONLY Application Accepte y Date /�-L6� � Area O 6 Pit or Grout Inspection by Date Final Inspection by Date 4K Additional Comments: ❑ Stk 466 8781 O Lodi 363621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 'i i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' :FEE' AMOUNT DUE AMOUNT REMITTED INFO' A K RECEIVED BY DATE7*9 ' PERMIT'-NO.' + EH 13-24(REV.1018331 5-1 j a EH W28 �t7 (-1 r�